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Malarone vs. Doxycycline (Doc V?)

Discussion in 'Diving Medicine' started by peterjmaerz, Feb 23, 2004.

  1. peterjmaerz

    peterjmaerz Barracuda

    # of Dives: 500 - 999
    Location: Ft. Lauderdale area
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    Doc Vikingo, if you're out there, or any other medical folks, I've narrowed my choices for anti-Malarials for use in PNG to the above. Without seeking official medical advice, I'd be interested in your personal opionion on which of the two you'd prefer.

    I've read reams of info ranging from the CDC's Division of Parasitic Diseases to the manufactuer's websites to many ScubaBoard postings. Just curious as to diving docs' most current opinions before visiting my GP.


    Thanks as always...


    Best,
     
  2. DocVikingo

    DocVikingo Senior Member Staff Member

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    Both are recommended for malaria chemoprophylaxis for this region. Both are fairly well tolerated. There is no reason to anticipate any problems under increased partial pressures of ambient air.

    Malarone has a simpler dosing schedule. Unless otherwise prescribed, you'll take one tablet daily starting 1-2 days before travel, daily during all travel & continue for 7 days after leaving the risk area. Side effects can include vomiting & itching of the skin.

    With doxycycline, unless otherwise prescribed you'll take one tablet daily for one week before travel, daily during all travel, and daily for 4 weeks after departing the risk area. An issue with doxycycline is it's potential to increase the sensitivity of the skin to sunlight, a real downside in places like PNG. It also can be rough on the GI tract, so watch for things like nausea, vomiting & diarrhea.

    The normally recommended course of Malarone will be somewhat more expensive than that of doxycycline (generic).

    Whichever drug you & your physician decide upon, you'll of course want to take all of the usual precautions against mosquito bites.

    This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

    Best regards.

    DocVikingo
     
  3. cdiver2

    cdiver2 Great White

    # of Dives: 500 - 999
    Location: Safety Harbor (West central) GB xpat
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  4. BlueDevil

    BlueDevil Barracuda

    # of Dives: 500 - 999
    Location: Melbourne, Australia
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    While on the topic of ant-malarials maybe one of the docs could give me some advice too? I will be travelling to vanuatu and my wife and I will be using doxycycline. The problem is what to use for the kids. I have a 7 yo and 10 yo. For the area we are travelling to the options are:

    Larium (easy dosing schedule, but some of the horror stories I have heard make me reluctant about this one)

    Doxycycline (probably ok for the 10 yo but not for the 7 yo)

    Proguanil and chloroquine combination (I believe one is taken daily and the other weekly, is chloroquine bitter tasting and if so will the kids take the stuff if it is that bad?)

    Thanks, BD
     
  5. beche de mer

    beche de mer Nassau Grouper

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    Antimalarials for kids is a perennial problem. Vanuatu is, overall, a high risk region for malaria, with high incidence of falciparum malaria - the nasty strain.

    However, Port Vila and environs are malaria-free, so if you're just going there, you and your family don't need to bother with anti-malarials at all. Likewise, if you're intending to stay in Vila and do day trips to places like Tanna and Espiritu Santo, no anti-malarials required.

    But if you're going to be away from Vila for more than a night, then you certainly should take anti-malarials. If it's a dive-trip, I expect you'll be visiting Santo for the Coolidge. Santo is malarious, including Lugainville.

    My advice for the kids would be either doxycycline for the 10 year old and Lariam for the 7 year old, or - my recommendation - Lariam for both. The 7 year old should not be given doxycycline, because of the risk of discolouration of adult teeth.

    There are lots of horror stories about Lariam, mostly exaggeration. The majority of people (and especially children, who haven't heard the stories) tolerate it quite well. The kids should be given a pro-rata dose, based on a dosage of 2 tablets per week for a 75Kg adult. If the kids are 30 to 40 kg in weight, they would need to take one tablet per week, commencing 2 weeks prior to arrival and continuing for 4 weeks after return to Australia.

    Chloroquine and Paludrine are not adequate for falciparum malaria. (And yes, its hard to get kids to swallow Chloroquine.)

    You should discuss this with a doctor at a Travel Clinic. You should attend at least 6 weeks prior to departure, to give plenty of time for completion of necessary vaccinations.
     
  6. DocVikingo

    DocVikingo Senior Member Staff Member

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    .... particularly if scuba is involved.

    From his post above: "There are lots of horror stories about Lariam, mostly exaggeration. The majority of people (and especially children, who haven't heard the stories) tolerate it quite well."

    Here is an unedited version of a piece from my "Ask RSD" column in the Nov '99 issue of "Rodale's Scuba Diving":

    "Lariam (mefloquine) is a very effective drug in preventing and treating malaria, but can give rise to unwanted side effects, including vivid & disquieting dreams, hallucinations, anxiety, depression, confusion and forgetfulness. The US package insert directs that "...caution should be exercised with regard to driving, piloting an airplane, and operating machinery as dizziness, a disturbed sense of balance, neurological or psychiatric reaction have been reported during and following the use of Lariam," and states that "dizziness, sensory & motor abnormalities, headache and fatigue have been recorded in patient's taking the drug."

    These cautions are consistent with suggestions by some in the medical and dive communities that mefloquine may produce side effects which mimic DCS.

    Of most concern to the diver are the positions of some medical professionals that the drug simply should not be taken for malaria prophylaxis by those who are actively diving. These sources include Rodale's Diving Doc," Dr. Samuel Shelanski, and the German Society for Tropical Diseases. This later group, whose policies can be used as a basis for professional and legal action in cases of harm resulting from a physician's failure to follow them, states that people with a special need for three-dimensional orientation, for example pilots, scuba divers and others, should not take mefloquine as prophylaxis. Similar advice regarding scuba diving is provided by Dr Bridget Farham, B.Sc (hons), Ph.D, MB.ChB., an expert on tropical medicines, and appears in the package insert accompanying mefloquine dispensed in South Africa.

    The above information suggests it would be prudent to take this drug only after detailed discussion with a physician who is fully aware of its current status, and to closely monitor for any adverse reaction."

    Since I wrote this, our FDA has gone so far as to write a special guide for it's use---->

    http://www.fda.gov/bbs/topics/NEWS/2003/NEW00921.html

    Finally, I have run across dive ops in the Australasia region that will not let you dive if you indicate that you are taking Lariam.

    Obviously, there is much to be considered before using mefloquine, especially during a diving vacation.

    DocVikingo
     
  7. beche de mer

    beche de mer Nassau Grouper

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    DocVikingo, I think you might have missed the point that Bluedevil was enquiring about malaria prophylaxis for his children, aged 7 and 10. I think it's safe to assume they won't be diving.

    The potential problems associated with Lariam have been well documented. Anecdotally, Lariam has a terrible reputation among travellers. Most studies show that the overall rate of side effects are about the same with Lariam as with Chloroquine/proguanil, and doxycycline - though the incidence of neuropsychiatric side effects is significantly higher. (But usually of milder grade - bizarre dreams, mild transient dysphoria, transient anxiety.)

    I doubt any travel physician who prescribes Lariam is "blase" about it. (Particularly in today's litiginous society.) I don't know of any travel physician who would recommend Lariam for someone actively engaged in scuba, aviation, high altitude activies, etc.

    We are always circumspect about prescribing Lariam. We usually look for alternatives, but sometimes it is clearly the best choice.

    Prescribing for children is always problematical. In general, Lariam is better tolerated by children than by adults. There are few effective alternatives for children below the age of 8 who are travelling to regions where falciparum malaria is endemic. Recently Malarone has become available to us, but at the cost of A$12 per tablet, the cost is frequently prohibitive. (And there are certain definite contra-indications for kids.)

    It's a difficult problem and I strongly recommend that Bluedevil discuss the matter at a specialised travel clinic.
     
  8. DocVikingo

    DocVikingo Senior Member Staff Member

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    Perhaps I read more into your statement, "There are lots of horror stories about Lariam, mostly exaggeration. The majority of people (and especially children, who haven't heard the stories) tolerate it quite well," than was actually implied.

    Best regards.

    DocVikingo
     
  9. BlueDevil

    BlueDevil Barracuda

    # of Dives: 500 - 999
    Location: Melbourne, Australia
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    Thanks for the information on anti-malarials and chidren. I visisted Vanuatu about 5 years ago when the kids where much younger and after much research and discussion with a travel medicine doctor I decided to not take them with me (but I had to promise my wife I would take her and the kids to Fiji 12 months later before she would let me go!!). This time I am committed to the trip and very keen to take the family (there is no way they will let me go on my own again!).

    We will be going to Santo, and in particular staying on Bokissa island. I believe the risk on Bokissa itself is relatively low, but certainly not zero. Preventative measures (DEET, clothing etc) will be a big part of our strategy.

    Doxycycline is said to have a cut off age of 8 years according to the literature. I am wondering how clearly defined this cutoff point is? For example is my 10 yo absolutely safe from any adverse dental effects? She is realatively small for her age and her second teeth are not all through yet. On the other end of the scale my 7yo will actually be 71/2 by the time we go. Does this mean that she is not safe to take doxycycline, but will be 100% safe six months later when she turns 8?

    Neither of my children have taken medication in tablet form, any medication they have had has been in liquid form. So the other consideration is what form the medication takes. Are any of the possible antimalarials available in liquid form? The next best choice may be a capsule (such as doxycycline) where we could open the capsule and mix the contents with food or drink. Another option would be a tablet that could be crushed and added to food or drink. Probably the worst option would be a large tablet that had to be swallowed whole.

    The once weekly dosing schedule of Lariam would be ideal, but i still have my doubts about giving to the kids. (As I said earlier my wife and I will be taking doxycycline since we are diving.)

    Thanks for any further info you can give. I will be visiting a travel medicine specialist but it is good to well informed about these issues before seeing the doctor so that a meaningful discussion can be had.

    Cheers, BD
     
  10. DocVikingo

    DocVikingo Senior Member Staff Member

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    (Q) "Doxycycline is said to have a cut off age of 8 years according to the literature. I am wondering how clearly defined this cutoff point is? For example is my 10 yo absolutely safe from any adverse dental effects? She is realatively small for her age and her second teeth are not all through yet. On the other end of the scale my 7yo will actually be 71/2 by the time we go. Does this mean that she is not safe to take doxycycline, but will be 100% safe six months later when she turns 8?"

    (A) As you may know, such discoloration is much more likely to be a problem in infants & younger children than in those ages 7-10. Nonetheless, the conservative short answer to your question is, "Probably not."

    The issue of tooth discoloration is more closely related to stage of tooth evolution than to simple chronological age. As in other areas of childhood physical (and mental) development, while the progression of stages tends to be relatively fixed, the ages at which these take place can vary substantially.

    I am asking our diving dental expert, Dr. Larry Stein, to respond to your inquiry.

    This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

    Best regards.

    DocVikingo
     

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